Saurabh Sethi

Adenosine triphosphate bioluminescence for bacteriologic surveillance and reprocessing strategies for minimizing risk of infection transmission by duodenoscopes

BACKGROUND AND AIMSnRecent outbreaks of duodenoscope-transmitted infections underscore the importance of adequate endoscope reprocessing. Adenosine triphosphate (ATP) bioluminescence testing allows rapid evaluation of endoscopes for bacteriologic/biologic residue. In this prospective study we evaluate the utility of ATP in bacteriologic surveillance and the effects of endoscopy staff education and dual cycles of cleaning and high-level disinfection (HLD) on endoscope reprocessing.nnnMETHODSnATP bioluminescence was measured after precleaning, manual cleaning, and HLD on rinsates from suction-biopsy channels of all endoscopes and elevator channels of duodenoscopes/linear echoendoscopes after use. ATP bioluminescence was remeasured in duodenoscopes (1) after re-education and competency testing of endoscopy staff and subsequently (2) after 2 cycles of precleaning and manual cleaning and single cycle of HLD or (3) after 2 cycles of precleaning, manual cleaning, and HLD.nnnRESULTSnThe ideal ATP bioluminescence benchmark ofxa0<200 relative light units (RLUs) after manual cleaning was achieved from suction-biopsy channel rinsates of all endoscopes, but 9 of 10 duodenoscope elevator channel rinsates failed to meet this benchmark. Re-education reduced RLUs in duodenoscope elevator channel rinsates after precleaning (23,218.0 vs 1340.5 RLUs, Pxa0< .01) and HLD (177.0 vs 12.0 RLUs, Pxa0< .01). After 2 cycles of manual cleaning/HLD, duodenoscope elevator channel RLUs achieved levels similar to sterile water, with corresponding negative cultures.nnnCONCLUSIONSnATP testing offers a rapid, inexpensive alternative for detection of endoscope microbial residue. Re-education of endoscopy staff and 2 cycles of cleaning and HLD decreased elevator channel RLUs to levels similar to sterile water and may therefore minimize the risk of transmission of infections by duodenoscopes.

Evolution in the utilization of biliary interventions in the United States: results of a nationwide longitudinal study from 1998 to 2013

BACKGROUND AND AIMSnBile duct surgery (BDS), percutaneous transhepatic cholangiography (PTC), and ERCP are alternative interventions used to treat biliary disease. Our aim was to describe trends in ERCP, BDS, and PTC on a nationwide level in the United States.nnnMETHODSnWe used the National Inpatient Sample to estimate age-standardized utilization trends of inpatient diagnostic ERCP, therapeutic ERCP, BDS, and PTC between 1998 and 2013. We calculated average case fatality, length of stay, patient demographic profile (age, gender, payer), and hospital characteristics (hospital size and metropolitan status) for these procedures.nnnRESULTSnTotal biliary interventions decreased over the study period from 119.8 to 100.1 per 100,000. Diagnostic ERCP utilization decreased by 76%, and therapeutic ERCP utilization increased by 35%. BDS rates decreased by 78% and PTC rates by 24%. ERCP has almost completely supplanted surgery for the management of choledocholithiasis. Fatality from ERCP, BDS, and PTC have all decreased, whereas mean length of stay has remained stable. The proportion of Medicare-insured, Medicaid-insured, and uninsured patients undergoing biliary procedures hasxa0increased over time. Most of the increase in therapeutic ERCP and decrease in BDS occurred in large, metropolitan hospitals.nnnCONCLUSIONSnAlthough therapeutic ERCP utilization has increased over time, the total volume of biliary interventions has decreased. BDS utilization has experienced the most dramatic decrease, possibly a consequence of thexa0increased therapeutic capacity and safety of ERCP. ERCPs are now predominantly therapeutic in nature. Largexa0urban hospitals are leading the shift from surgical to endoscopic therapy of the biliary system.

Radiation-Free ERCP in Pregnancy: A “Sound” Approach to Leaving No Stone Unturned

A 29-year-old 14-week pregnant woman was initially evaluated at an outside hospital with complaints of right upper quadrant pain, fever, and chills. There was no significant past medical history. Her vital signs were stable, and the clinical examination was significant only for right upper quadrant tenderness. Laboratory evaluation revealed a white cell count (WBC) 11.8 9 10/lL, total bilirubin (TB) 3 mg/dL, alanine transaminase (ALT) 86 U/L, aspartate transaminase (AST) 101 U/L, and alkaline phosphatase (AP) 104 U/L. A right upper quadrant ultrasound revealed gallstones, gallbladder wall thickening, peri-cholecystic fluid, and a dilated common bile duct (10 mm) without any evidence of bile duct stones. She underwent laparoscopic cholecystectomy for acute cholecystitis, with an intraoperative cholangiogram, bile duct exploration, and extraction of a bile duct stone. She was readmitted 2 days later with abdominal pain and an increasing total bilirubin. Laboratory examination revealed WBC of 8 9 10/lL, TB 5.3 mg/dL, ALT 90 U/L, AST 128 U/L, and AP 155 U/L. Right upper quadrant ultrasound revealed a dilated bile duct (11 mm) without any evidence of bile duct stones. Due to concern about ongoing biliary obstruction, she underwent single-session endoscopic ultrasound (EUS)-guided endoscopic retrograde cholangio-pancreatography (ERCP) without planned use of fluoroscopy, performed under general anesthesia. Initial endoscopic ultrasound (EUS) determined that one small stone was obstructing just proximal to the ampulla. The common bile duct diameter was 12 mm, and approximate bile duct length from the ampulla to the bifurcation was 9 mm (Figs. 1, 2). ERCP was then performed without use of fluoroscopy. Deep selective biliary cannulation was accomplished with a sphincterotome with bile duct access confirmed by bile aspiration. A biliary sphincterotomy was performed, followed by stone extraction using a balloon catheter inflated to the approximate diameter of the bile duct and advanced to the approximate length of the bile duct to the bifurcation previously determined by EUS (Figs. 3, 4). Additional balloon sweeps were performed with no more stones extracted. The procedures were followed by resolution of the patient’s abdominal pain and normalization of liver function tests (LFTs). The patient was discharged home and has remained well since.

Outcomes of endoscopic treatment of second recurrences of large nonpedunculated colorectal adenomas

AbstractBackground and aimsnnPiecemeal endoscopic mucosal resection (EMR) of large nonpedunculated colorectal adenomas is associated with significant recurrence rates. After salvage endoscopic treatment of recurrences, there is a significant rate of second recurrences. There is a paucity of data on the efficacy and safety of continued endoscopic treatment after a second recurrence.MethodsConsecutive patients with recurrent adenomas after initial piecemeal EMR of nonpedunculated colorectal adenomas >2xa0cm were reviewed. We assessed the feasibility, safety and efficacy of continued endoscopic treatment in these patients.ResultsSixty-four patients with 70 recurrent lesions were identified. All were retreated endoscopically. Follow-up colonoscopy (mean interval 6.4xa0months) was performed on 62/70 lesions (89xa0%), and a second recurrence was found in 21/62 (34xa0%). One patient underwent surgery for a circumferential adenoma of the ileocecal valve. The other 20 lesions were treated endoscopically. Follow-up colonoscopy was performed on 15/20 (75xa0%) and demonstrated a third recurrence in 3/15 (20xa0%). One was a deep T1 cancer; curative surgery was performed. The other two patients each had one additional endoscopic treatment and both had no recurrence on subsequent colonoscopy. There were two complications: Both were delayed bleeds after treatment of the first recurrence. A mean of 1.3 endoscopic procedures was required to achieve a cure (range 1–3) for recurrent adenomas after piecemeal EMR.ConclusionEndoscopic treatment of patients with second recurrences is safe and effective, but is associated with a significant rate of additional recurrences. Continued endoscopic treatment of patients with multiple recurrences is associated with high cure rates, low complication rates and a low risk of progression to malignancy.

Good Vibrations: Successful Endoscopic Electrohydraulic Lithotripsy for Bouveret’s Syndrome

A 51-year-old woman was initially evaluated in the Emergency Department with a 6-week history of upper abdominal pain, nausea, and vomiting. There was no significant past medical history. Vital signswere stable; the examinationwas significant only for right upper quadrant tenderness. Abdominal CT scan revealed the presence of a large fistula between gallbladder and the duodenum. A large, partially calcified gall stone was located in the proximal duodenum. At endoscopy, a gallstone was visualized in the duodenal bulb (Fig. 1), which upon probing was deeply impacted between the duodenum and the fistula, thwarting attempts at dislodgement with a balloon catheter. Using a doublechannel gastroscope, an electrohydraulic lithotripsy (EHL) probe was advanced through a biliary cannula with a cut distal end through one channel while continuous water irrigation was applied through the second channel to achieve adequate water immersion of the stone for lithotripsy. EHL was repeatedly applied to crack the stone with subsequent applications to break the stone into multiple fragments (Fig. 2). Loose stone fragments were dragged into the stomach with a snare, in order to prevent escape into the small bowel with consequent obstruction of the terminal ileum due to gallstone ileus. The fistula was then examined with the endoscope advanced into the gallbladder under fluoroscopic guidance. A cholangiogram revealed no other stones in the gallbladder or in the bile duct (Fig. 3). The post-bulbar duodenum was also normal. Larger stone fragments were not retrieved to avoid esophageal mucosal laceration upon withdrawal and were instead crushed with a mechanical lithotriptor (Fig. 4). Small stone fragments in the fundus were then removed using a Roth net. The patient was subsequently discharged home with no further complaints or issues noted.

A prospective evaluation of radiation-free direct solitary cholangioscopy for the management of choledocholithiasis

BACKGROUND AND AIMSnEndoscopy has replaced many radiologic studies for the GI tract. However, ERCP remains a hybrid endoscopic-fluoroscopic procedure, which limits its portable delivery, creates delays because of fluoroscopy room unavailability, and exposes patients and providers to radiation. We evaluated fluoroscopy/radiation-free management of patients with noncomplex choledocholithiasis using direct solitary cholangioscopy (DSC).nnnMETHODSnPatients underwent fluoroscopy-free biliary cannulation, sphincterotomy, and then cholangioscopy to establish location and number/size of stones and to document distance from ampulla to bifurcation to guide balloon advancement. Stones were extracted using a marked balloon catheter advanced to the bifurcation and inflated to the bile duct diameter, documented on prior imaging. Repeat cholangioscopy was performed to confirm stone clearance.nnnRESULTSnFluoroscopy-free biliary cannulation was successful in all 40 patients (100%). Advanced cannulation techniques were required in 5 patients. Papillary balloon dilation was performed in 8 patients and electrohydraulic lithotripsy in 3 patients. Discrete stones were visualized in 31 patients and stone debris/sludge in 8 patients. Fluoroscopy-free stone/debris/sludge extraction was successful in all these patients. Brief fluoroscopy was used in 2 patients (5%) to confirm stone clearance. No stone/debris/sludge was noted in 1 patient. Mild pancreatitis was noted in 2 patients (5%) and bleeding in 1 (2.5%).nnnCONCLUSIONSnThis study establishes the feasibility of fluoroscopy/radiation-free, cholangioscopic management of noncomplex choledocholithiasis with success and adverse event rates similar to standard ERCP. DSC represents a significant procedural advance in the management of biliary disorders that does not need to be confined to the fluoroscopy suite and can be reimagined as bedside procedures in emergency department or intensive care unit settings. (Clinical trial registration number: NCT03074201.).

Rendezvous EndoSeel Technique for Non-operative Closure of Anastomotic Leak After Ileoanal Pouch Operation

Surveillance colonoscopy of a 50-year-old woman with a 30-year history of ulcerative colitis revealed multifocal high-grade dysplasia, which was treated with laparoscopic total proctocolectomy and ileoanal anastomosis with the creation of an ileal reservoir (J-pouch) and a diverting ileostomy. On postoperative day 5, fever with leukocytosis with purulent discharge from a pelvic Jackson-Pratt (JP) drain was noted. Rigid sigmoidoscopy revealed an intact ileoanal anastomosis with a leak along the posterior midline at the J-pouch anastomotic staple line, *7 cm proximal to the anal verge. Subsequent contrast-enhanced CT scan revealed the interim development of a postoperative pelvic abscess dissecting into the anterior abdominal wall (Fig. 1). Flexible sigmoidoscopy revealed a 10 mm 9 10 mm anastomotic dehiscence; the JP drain was visualized in the abscess cavity (Fig. 2). Endoscopic closure was accomplished using the new over-the-scope clip (OTSC) system: Under endoscopic guidance, the indurated and edematous edges of the dehiscence were grasped and approximated using a twin grasper, which was then retracted into the applicator cap. Applied suction brought the edges of the dehiscence into the applicator cap which then enabled the successful deployment of OTSC, completely closing the leak endoscopically (Fig. 3). Subsequently, drainage of the abdominal and pelvic abscesses by interventional radiology (IR) facilitated discharge home with oral antibiotics 8 days after the endoscopic intervention. Subsequent imaging of the abscess cavity on the 21st and 35th days revealed persistent small anastomotic leaks at the level of the OTSC clip (Fig. 4a), which was treated with 3 cc of serosal Tisseel fibrin sealant through the IR-placed drain (Fig. 4b). Barium contrast enema on the 42nd day confirmed complete closure of the anastomotic leak (Fig. 5).

Au Naturel: Transpapillary Endoscopic Drainage of an Infected Biloma

A 35-year-old man was transferred to our tertiary care academic medical center from an outside urgent care facility where he had complained of a 3-day history of right upper quadrant abdominal pain, jaundice, and fever of up to 39.1 C. His past medical history was notable for cholecystitis and gallstone pancreatitis 6 months previously, managed at an outside facility by laparoscopic converted to open cholecystectomy. The surgery was complicated by an inadvertent injury to the right hepatic duct and resultant bile leak for which intraoperative primary repair was performed and a surgical drain was placed. On postoperative day 6, his drain was removed, and he was discharged home. Vital signs at his current presentation were notable for a heart rate of 117 beats/min, temperature of 38.2 C, blood pressure of 106/68 mm of Hg, and respiratory rate of 17/min. Physical examination revealed right upper quadrant abdominal tenderness without guarding or rigidity. His WBC count was 8.2 K/lL (4.0–11.0 K/lL) with 85% neutrophils. Other abnormal laboratory results included a total bilirubin of 6.0 mg/dL (normal1.4 mg/dL), alkaline phosphatase of 423 U/L (normal130 U/L), and alanine aminotransferase (ALT) of 240 U/L (normal60 U/L). An abdominal ultrasound reported a 4.7-cm collection in the gallbladder fossa with an associated fluid/debris level raising concern for an infected biloma. Moderate intrahepatic biliary dilation was also seen (Fig. 1a). A computerized tomography (CT) scan of the abdomen demonstrated a fluid collection in the gallbladder fossa which appeared complex, containing internal debris. Intrahepatic biliary dilation was noted with possible compression effect at the level of the fluid collection (Fig. 1b). The overall clinical picture suggested a biloma that was possibly infected and juxtaposed hilar biliary obstruction with concern for cholangitis. The interventional radiology team was consulted, but they felt that the biloma would not be easily amenable to percutaneous drainage due to its location. The patient was therefore referred to interventional endoscopy to perform endoscopic retrograde cholangiography (ERCP) for management of the biliary obstruction. At ERCP, contrast injection revealed a tight common hepatic duct stricture commencing just distal to the bifurcation and extending a short distance into the right and left main hepatic ducts (Fig. 2). Extravasation of contrast was noted from a bile duct defect just below the bifurcation, opacifying the biloma (Fig. 2). Given that the biloma communicated with the bile duct, a decision was made to advance a transpapillary stent into the biloma cavity in order to accomplish drainage. Guidewires were advanced into the right and left main hepatic ducts and through the bile duct defect into the biloma cavity. Two 7 Fr 9 12 cm plastic stents were then advanced into the left and right main hepatic ducts for stricture management. An additional 7 Fr 9 12 cm plastic stent was advanced across the ampulla into the biloma cavity. Advancement of the third stent into the biloma cavity resulted in drainage of a significant volume of pus (Fig. 2). Monique Barakat and Shivangi Kothari have contributed equally to this manuscript.

Primary Gastric Hodgkin's Lymphoma: An Extremely Rare Entity and A Diagnostic Challenge.

A 71-year-old man was admitted to Stanford University Hospital with a 1-year history of poor appetite, 20 lbs weight loss, and recent episodes of hematemesis. He did not complain of abdominal pain, dysphagia, odynophagia, fever, or chills. His past medical history was significant for hypertension and gastro-esophageal reflux disease. The family and social history were unremarkable. Physical examination revealed a thin male with normal vital signs. There was no peripheral lymphadenopathy, and examination of the abdomen was unremarkable, with no enlargement of the liver or spleen or ascites. Laboratory investigations revealed iron deficiency anemia with a hemoglobin of 7.5 g/dL, WBC of 7,100/lL, and platelet count of 365,000/lL. His serum electrolytes and liver function tests were normal. Blood transfusion was declined due to religious beliefs. He was treated with intravenous iron and erythropoietin. An upper gastrointestinal endoscopy revealed a large fungating mass (*4.5 cm in maximum diameter) (Fig. 1), involving the gastric fundus and cardia, which on histological examination revealed only atypical cells without clear evidence of malignancy. Colonoscopy was normal; a CT of his chest, abdomen, and pelvis documented thickening of the gastric wall, consistent with his known gastric mass. There was no evidence of pathological lymphadenopathy or local, regional, or distant metastases. Due to the lack of a clear pathological diagnosis, upper gastrointestinal endoscopy was repeated. Histological examination of gastric biopsies again revealed only ulceration and necrosis with only one biopsy sample positive for atypical cells. Pan-cytokeratin immunostaining was negative for infiltrating epithelial cells, while no increase in B cells was apparent with CD20 immunostaining. Urease testing for Helicobacter pylori was negative. An endoscopic ultrasound (EUS) confirmed an irregular mass with poorly defined borders and heterogeneous echogenicity, 29 9 30 mm in maximal cross-sectional diameter (Figs. 2, 3). There was sonographic evidence suggesting invasion into the serosa. Fine needle aspiration (FNA) was performed. Cytologic examination again reported atypia. A clear pathological diagnosis remained elusive. Given the high suspicion for malignancy, the patient underwent yet another upper endoscopy during which deep ‘‘jumbo’’ forceps biopsies of the mass were obtained. Histological examination on this occasion revealed ulcerated mucosa with an underlying mixed inflammatory infiltrate, including lymphocytes, plasma cells, and eosinophils. Against this background were scattered atypical cells with large nuclei and prominent nucleoli. Rare bi-lobed cells resembling Reed–Sternberg cells were also observed (Figs. 4, 5). The large cell population expressed CD30 and CD15 (Figs. 6, 7). Faint nuclear staining was present for PAX-5; in situ hybridization with the Epstein–Barr virus-encoded RNAs (EBER-1) as a probe for Epstein–Barr virus (EBV) S. Sethi S. Banerjee (&) Division of Gastroenterology and Hepatology, Stanford University, Stanford, CA, USA e-mail: sbanerje@stanford.edu